Provider Demographics
NPI:1710137773
Name:NIRVANA LLC
Entity Type:Organization
Organization Name:NIRVANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:RAYE
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:505-553-6850
Mailing Address - Street 1:161 RAILCAR RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-7909
Mailing Address - Country:US
Mailing Address - Phone:505-553-6850
Mailing Address - Fax:
Practice Address - Street 1:161 RAILCAR RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-7909
Practice Address - Country:US
Practice Address - Phone:505-553-6850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH986124Q00000X
NMDH1235124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65028066Medicaid